APPLICATION FOR EMPLOYMENT
IBERIA MEDICAL CENTER OFFERS EQUAL EMPLOYMENT OPPORTUNITY TO ALL APPLICANTS FOR
EMPLOYMENT AND TO ALL EMPLOYEES REGARDLESS OF SEX, AGE, RACE, COLOR, RELIGIOUS
CREED, NATIONAL ORIGIN, ANCESTRY, MARITAL STATUS, OR DISABILITY.
PLEASE PRINT CLEARLY
PERSONAL DATA
Date _______________________
Name ________________________________________________________
Last Name
First Name
MI
Present Address __________________________________________________________
Street Number and Name
__________________________________________________________
City
State
Telephone
(
)
Message
Telephone
(
)
Zip Code
E-mail ______________________________________________________
Other names under which you have worked (maiden last name, different first name, etc)_____________________
___________________________________________________________________________________________
Are you a U.S. Citizen or authorized to work in the U.S. on an unrestricted basis?
____ Yes
____ No
Are you at least 18 years of age?
____ Yes
____ No
Person to be notified in an emergency
___________________________________________________________________________________________
Name
Address
Telephone
POSITION DESIRED
Position(s) applying for __________________________________________________________________
Salary requirement ____________________________
Specify: _____ Full-time
_____Part-time
_____Relief
Shift preferred _________
Were you previously employed by Iberia Medical Center?
____ Yes
____ No
If yes, when and where? _____________________________________________
If an offer is extended, when would you be available for work? _______________________________________
How did you become aware of the position for which you applying? Please give individual’s name or source.
___________________________________________________________________________________________
Do any of your relatives work for Iberia Medical Center? ____ Yes _____ No
If yes, who and your relation? _________________________________________
Do you have a reliable method of transportation to use if hired to work in this facility?
____ Yes
____ No
EMPLOYMENT HISTORY (must be completed in full to be considered for employment)
Are you presently employed?
____ Yes ____ No
May we contact your present employer?
____ Yes ____ No
List your work experience, beginning with your most recent job
FROM (Mo/Yr)
TO (Mo/Yr)
NAME & ADDRESS OF EMPLOYER
JOB TITLE & DUTIES
__________________________________
_______________________
__________________________________
_______________________
__________________________________
_______________________
Starting Salary
Ending Salary Supervisor ________________________
Reason for Leaving
_____________ ____________ Phone ____________________________
______________________
FROM (Mo/Yr)
TO (Mo/Yr)
NAME & ADDRESS OF EMPLOYER
JOB TITLE & DUTIES
__________________________________
_______________________
__________________________________
_______________________
__________________________________
_______________________
Starting Salary
Ending Salary Supervisor ________________________
Reason for Leaving
_____________ ____________ Phone ____________________________
______________________
FROM (Mo/Yr)
TO (Mo/Yr)
NAME & ADDRESS OF EMPLOYER
JOB TITLE & DUTIES
__________________________________
_______________________
__________________________________
_______________________
__________________________________
_______________________
Starting Salary
Ending Salary Supervisor ________________________
Reason for Leaving
____________
____________ Phone ____________________________
______________________
FROM (Mo/Yr)
TO (Mo/Yr)
NAME & ADDRESS OF EMPLOYER
JOB TITLE & DUTIES
__________________________________
_______________________
__________________________________
_______________________
__________________________________
_______________________
Starting Salary
Ending Salary Supervisor ________________________
Reason for Leaving
____________
____________ Phone ____________________________
______________________
FROM (Mo/Yr)
TO (Mo/Yr)
NAME & ADDRESS OF EMPLOYER
JOB TITLE & DUTIES
__________________________________
_______________________
__________________________________
_______________________
__________________________________
_______________________
Starting Salary
Ending Salary Supervisor ________________________
Reason for Leaving
____________
____________ Phone ____________________________
______________________
EDUCATION AND TRAINING (must be completed in full to be considered for employment)
Name and Address of School
No of years completed
Course or Major
Diploma/Degree
Professional License No.
Type of License
Place of Issue
Expiration Date
Membership(s) in professional organizations
Name and Occupation
REFERENCES (DO NOT LIST RELATIVES)
Address
EXPERIENCE (Check all that apply)
Phone Number
CLERICAL
NURSING
_____ Accounting
_____Secretary/Steno
_____Operating Room _____Pediatrics
_Surgery
_____Admissions
_____Collections/Credit
_____Emerg Room
_____Psychiatric
_____Oncology
_____Unit Secretary _____Human Resources
_____ICU
_____Isolation
_____Urology
_____Cashier
_____Insurance
_____Medical
_____Surg ICU
_____OB/Gynec
_____Payroll
_____Medical Records
_____Orthopedics
_____Education
_____Geriatrics
_____Transcription
_____Public Relations
_____Hemodialysis
_____Supervisory
OTHER
_____ Pharmacy _____X-Ray Tech
_____Respiratory Therapy _____Cardio Pulmonary _____Cardiac Cath
OPERATIONS AND MAINTENANCE DIVISION
_____Building Trades _____Food Preparation
_____Housekeeping
_____Groundskeeper
_____Purchasing
_____Engineering
_____Food Service
_____Carpet/Floor Cleaner
_____Electronics
_____Maintenance
_____Heating/Air-Conditioning
_____Dictaphone
_____Office Copier
_____Typing speed (wpm)
_____Adding Machine _____PBX
_____Fax Machine
_____Shorthand speed (wpm)
_____Computer
_____Bookkeeping
_____Calculator
SPECIAL SKILLS
_____Keypunch
_____Word processor
Software_________________________________________________________
Do you speak, read, or write in any language other than English?
_____yes
_____no
If yes, please describe____________________________________________________________________
_____________________________________________________________________________________________________________________
PLEASE USE THE SPACE BELOW FOR ANY COMMENTS YOU WOULD LIKE TO MAKE REGARDING
YOUR QUALIFICATIONS FOR THE POSITION(S) FOR WHICH YOU ARE APPLYING.
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
I hereby certify that the answers to the foregoing questions are true to the best of my knowledge and agree to have
any of the statements checked by Iberia Medical Center unless I have indicated to the contrary.
I am aware that a more detailed investigation concerning background may also be conducted, if applicable to the job
for which I am applying and I hereby authorize such an investigation.
I understand that employment is contingent upon satisfactory completion of reference checks and that, upon my
written request, information on the nature and scope of an inquiry, if one is made, will be provided to me.
I understand that I am required to disclose whether I am an Ineligible Person and I will checked against the GSA and
HHS-OIG Exclusion Lists prior to hiring and that IMC requires me to immediately disclose any debarment,
exclusion, or other event that makes me an Ineligilble Person.
Should a job offer be made, I consent to taking a pre-placement physical examination and such future examinations
as may be required by Iberia Medical Center. I understand that any job offer or my continuing employment, if hired,
is contingent upon my being physically, mentally and medically able, with or without reasonable accommodation, to
successfully perform the essential functions of my job, I understand that as part of my pre-placement physical
examination, upon which any offer of employment is contingent, I will be required to successfully pass a drug
screening test. The test will be administered at Iberia Medical Center’s expense, and will require me to provide a
urine specimen for analysis. Proof of prescription drugs will be required. Results of the drug test are confidential,
and will not be disclosed to others without a need to know. My signature below specifically signifies my consent to
this pre-placement drug screening test.
I agree to wear or use all protective clothing or devices required by the facility and to comply with all safety policies
and procedures.
I understand that nothing contained in this employment application is intended to lead to or create an employment
contract between Iberia Medical Center or affiliate and myself which would in any way restrict the right of the
hospital to terminate my employment at will.
I further understand and agree that the employment relationship that may result from my application will be
employment-at-will, and either I or Iberia Medical Center or affiliate may terminate the relationship at any time.
I understand that any misrepresentation or falsification can be grounds for refusal of employment. I further
understand that, if employed, any false statements or misrepresentations herein or in conjunction with the
application process is cause for dismissal.
I understand that this application will be active for a period of 6 months and kept on file for 1 year; after that time, if
I wish to be considered for employment, I must submit a new application.
Applicant’s Signature_____________________________________________________ Date__________________
IBERIA MEDICAL CENTER BEHAVIORAL STANDARDS
“MAKING A PROMISE WORTH KEEPING”
P-PROFESSIONALISM:
I will smile and greet others with eye contact.
I will maintain a pleasant and calm demeanor in all situations.
Iwilldresscleanlyandneatlywhiledisplayingmynamebadgeproudly.
Iwillalwaysspeakandbehavepositivelyaboutmycareerandencourage
otherstodoso.
Iwillnotuseelectronicdevicesforpersonaluse.(Example:cellphones,
iPads,etc.)
R-RESPECT:
Iwillrememberconfidentialitybyspeakingaboutpatientinformationina
privatemanner.
Iwillrecognize,praise,andthankmyco-workers,physicians,aswellas
patients.
O-OWNERSHIP:
IwillstrivetomakeIMCthebestchoiceforourcommunity.
Iwillneverusethephrase“that’snotmyjob”.
Iwillofferassistancetopatients,co-workersandphysicians.
M-MANAGE:
Iwillspeakpositivelyofothersintheirpresenceorabsenceonoroffduty,
andonallsocial
mediasites.
IwillprotectthefutureofIMCbynotwastinghospitaltimeandresources.
Iwillalwaysmanageupbyportrayingconfidenceinourfacility,myselfand
allco-workers.
I-INFORM:
Iwillexplaindetailsofeachproceduretopatientsandfamilymembers.
Iwillnotifypatientsandfamilymembersofwaittimesanddelays.
Iwillcommunicatewithco-workerstoachieveexcellentoutcomes.
Iwillactquicklyandinformtheproperchainofcommandaboutany
complaintsorconcerns.
S-SAFETY:
IwillkeepIMCsafeandclean.
Iwillpickuptrashindoorsandoutdoors,cleanlinessiseveryone’sjob.
Iwilladdresssafetyconcernsimmediatelywhenobserved.
Iwillpolitelynotifysmokersofourtobaccofreepolicywithasmile.
E-EXCELLENCE:
Iwillhelpothersfindtheirwaybywalkingwiththemtotheirdestination.
Iwillofferassistanceinsteadofwaitingtobeaskedwhensomeoneseems
lost.
Iwillalwaysask“IsthereanythingelseIcandoforyou?”
Iwillputforththeefforttobeexcellent.
IwillembracechangeandcontinualimprovementtoensureIMCalways
providesexcellentservice.
IhavereadtheIMCServiceExcellencePromisesandIampersonallycommittedtoembrace,follow,and
liveourvisionand“PROMISE”tobethehospitalofchoiceforpatients,physiciansandemployees.I
understandthatifIfailtofollowthis“PROMISE”toIMC,Imaybeterminatedfrommyemployment.
_________________________________________________________________
EmployeeSignatureDate
IBERIA MEDICAL CENTER
VERIFICATION OF EMPLOYMENT
Applicants: Please only read and sign the bottom portion of this page, authorizing Iberia Medical
Center to verify previous employment.
Date:
______________________________
2315 East Main Street
TO:
______________________________
New Iberia, LA 70560
______________________________
(337) 374-7601
______________________________
Fax: (337) 374-7655
______________________________ has applied for a position as
______________________________ in this institution.
We would appreciate if you would answer the following questions so that we may reach a fair decision. We would
hold in strict confidence, any information that you may give us concerning this applicant.
Thank you for your prompt attention.
___________________________________
Dates of Employment:
________thru_________
Job Title:___________________________Date of Termination: _________________
Reason for Termination:_________________________________
Please evaluate applicant on following points:
Interpersonal Skills _____
Reaction under Stress_____
Honesty_____
Job Knowledge _____
Eligible for Employment?
1 – Excellent 2-Good 3 - Satisfactory
4 - Fair
5 - Poor
Attendance _____
Work Habits_____
Initiative _____
Dependability _____
______Yes
Adaptability _____
Efficiency
_____
Responsibility _____
_____No
Signature
Title
Date
I authorize any individual, company, institution or agency to give any information regarding my previous
employment, to Iberia Medical Center, and hereby release the organization from any liability for all damages
resulting in any information furnished to them.
___________________________________________
Applicant
____________________________
Date
IBERIA MEDICAL CENTER
VERIFICATION OF EDUCATION
Applicants: Please only read and sign the bottom portion of this page, authorizing Iberia Medical
Center to verify your educational record.
Date:
TO:
2315 East Main Street
______________________________
(name of school)
______________________________
(address of school)
______________________________
New Iberia, LA 70560
(337) 374-7601
Fax: (337) 374-7655
______________________________ has applied for a position at Iberia Medical Center.
We would appreciate if you would answer the following questions so that we may verify the education information
submitted by the applicant. We will hold all information supplied by you in strict confidence.
Thank you for your prompt attention.
Sheila Champagne
Hiring Specialist
Dates of Education: ________thru_________
Diploma Received: __________________________, _________________
(type of diploma)
(date of completion)
I authorize any individual, company, institution or agency to give any information regarding my previous education,
to Iberia Medical Center, and hereby release the organization from any liability for all damages resulting in any
information furnished to them.
___________________________________________
Applicant
____________________________
Date